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transcript
Practical Medical Physics
Session: TG-151
Dose Monitoring
August 5, 2013
Katie Hulme, M.S.
Digital Imaging and ‘Dose Creep’
Under-Exposed Over-Exposed
Images courtesy of Agfa Healthcare©
Freedman et al., The potential for unnecessary patient exposure from the use of storage phosphor imaging systems, SPIE Medical Imaging,
SPIE Proceedings 1897, 472-479 (1993)
Gur et al., Natural migration to a higher dose in CR imaging, Proceedings of the Eight European congress of Radiology, 154 (1993)
Dose Tracking – Annual
(Physicist)
• Tube Output, HVL
• Incident Air Kerma (Ka,i) Measurements - ‘typical’ doses
- references for limits / reference levels:
• NCRP 172
• NEXT Surveys
• State regulations
• AEC evaluation - EI is useful for this as well!
- TEIs will be correlated w/ cutoff dose
• Accuracy of metric used for ongoing QC - DAP, EI, etc.
CCF Patient Incident Air
Kerma (IAK) • GOAL:
- to reduce patient doses for common radiographic
exams to below 3rd quartile NEXT* data for ALL
sites
*NEXT = National Evaluation of X-Ray Trends( CRCPD Pub. No. E. 03-2)
Where we were…
EXCEEDING NEXT 3rd
QUARTILE
Where we were…
0
10
20
30
40
50
60
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
Mo
re
Fre
qu
en
cy
kVp Bin
AP Abdomen
Frequency
EXCEEDING NEXT 3rd
QUARTILE
CCF Patient Incident Air
Kerma (IAK) • HOW:
- kVp standardization for select exams • Enables comparison of IAKs between sites with same system
- Development and documentation of image-based
methodology for in-house AEC evaluation and
calibration
- Instituted new CCF limit for IAK • Identify outliers during annual testing
*NEXT = National Evaluation of X-Ray Trends( CRCPD Pub. No. E. 03-2)
CCF IAK Limits
CCF IAK Limits
TX
Min Max Q3 Q3 Av Av Limit
(mGy) (mR) (mGy) (mR) (mR) (mR) (mGy) (mR) (mGy) (mR) (mR)
AP Abdomen 5.26 600 3.40 388 300 490 3.469 396 2.374 271 450
AP Lumbar 6.13 700 4.20 479 4.179 477 2.996 342 550
AP Thoracic 3.50 400 2.27 325 325
AP Cervical 1.75 200 1.75 200 1.183 135 120
LAT Skull 1.75 200 1.75 200 1.270 145 150
DP Foot 0.88 100 0.31 35 8 35 50
PA-AP Chest w/ Gr 0.35 40 0.26 30 10 15 0.158 18 0.114 13 30
PA-AP Chest woo Gr 0.26 30 0.18 20 0.123 14 0.079 9 20
PA-AP Chest w/ Gr 0.35 40 0.26 30 10 15 0.158 18 0.114 13 30
NEXT DataODH
Limit
CRCPD, Pub No. E-03-2, Table 4
NEXT DataCCF ESE
Standard
ESE Range
quoted by
ODH
NEXT = National Evaluation of X-Ray Trends
CRCPD = Conference of Radiation Control Program Directors
References: Diagnostic Reference
Levels (DRLs)
• NCRP Report No. 172, Reference levels and achievable doses in medical and dental
imaging: recommendations for the United States. (2012)
• ACR Practice Guideline for Diagnostic Reference Levels in Medical X-Ray Imaging.
(Revised 2008, Resolution 3).
• Gray et al., Reference Values for Diagnostic Radiology: Application and Impact,
Radiology Vol 235 (2):p354-358, 2005.
• Nationwide Evaluation of X-ray Trends (NEXT): Tabulation and Graphical Summary
of 2002 Abdomen/Lumbosacral Spine Survey. CRCPD Publication E-06-2b (2006).
• Nationwide Evaluation of X-ray Trends (NEXT) : Tabulation and Graphical Summary
of 2001 Survey of Adult Chest Radiography. CRCPD Publication E-05-2 (2005).
• Nationwide Evaluation of X-ray Trends (NEXT) : Tabulation and Graphical Summary
of 1998 Pediatric Chest Survey. CRCPD Publication E-04-5 (2004).
Ka,i - Limitations
• ‘Average’ patient doses do not necessarily
reflect actual patient dose or the distribution
in patient doses - Measurements do not indicate adherence to technique
charts (manual)
• Phantoms represent a limited range of exam
types and body parts
• Metrics are not suitable for ONGOING QC - Require a level of expertise (and equipment) to measure
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
Dose Tracking – Ongoing
• Exposure Index
- DICOM tags*: EI(0018,1411), TEI (0018,1412), DI (0018,1413)
- Available for all systems that have adopted IEC standard
• Entrance Dose
- DICOM tags:
• Entrance Dose (0040,0302)
• Entrance Dose in mGy (0040,8302)
- Available on systems with integrated generator
• Area Dose Product
- DICOM tag:
• Image and Fluoroscopy Area Dose Product (0018,115E)
- Available on systems with integrated generator
WHAT INFORMATION IS AVAILABLE TO YOU??
*DICOM Correction item 1024 – ‘Exposure Index Macro’
Exposure Index (IEC 62494-1 )
)(0 VgcE I
• Where
- V is the Value of Interest
- g(V) is the inverse calibration function
- C0 = 100 µGy-1
Exposure Index
• Advantages - Reflects receptor dose
- Not as dependent on patient size/distribution
- Standardized metric
• Disadvantages - Indirectly related to patient dose
- Depends on beam quality, exam/view, as well as vendor-
defined VOI
- Collimation, prosthetics, etc. can affect calculated value
Entrance Dose
• Incident air kerma (Ka,i) at a fixed location
- Reference point varies among vendors
• Typically derived from exam parameters
• kVp / mAs
• not measured on a patient by patient basis
Entrance Dose
• Advantages - Can be used to estimate patient dose
• Disadvantages - No standard reference point or method for normalization
- Entrance surface of patient may deviate from reference point
- Does not represent size of the x-ray field
• Most data from Europe - But often limited to certain body habitus range
• i.e. 65-75 kg, Hart 2003
- Most US data currently w/ respect to phantoms
Image and Fluoroscopy Area
Dose Product
• Product of the x-ray field size and air kerma
- Dose Area Product (DAP)
- Kerma Area Product (KAP)
- Air Kerma-Area-Product (PKA)
- Unit DICOM field: dGy-cm2
• Often measured using a PKA meter installed
on the collimator
PKA
• Advantages
- Contains information about Ka,i AND field size
• Enables assessment of both patient dose and
collimation
- Field size can be derived if Ka,i is known (or
estimated)
• Disadvantages
- DAP meter option may have to be purchased
separately
- Difficult to isolate impact of collimation without
knowledge of Ka,i
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
Exposure Index (IEC 62494-1 )
• IEC 62494-1 standard states that the
EI shall be calibrated such that:
• Where
- KCAL is the receptor air kerma (in µGy)
under calibration conditions
- C0 = 100 µGy-1
C A LKcE I 0
Exposure Index (IEC 62494-1 )
• Inverse calibration function is
defined as:
• Inverse calibration function should
have an uncertainty of less than 20%
)()( 1
C A LC A LC A L VfVgK
Calibration Conditions (IEC 62494-1 )
• Fixed radiation quality
- RQA5
• Homogenous irradiation of image
receptor
• Measurement of incident air kerma
(free in air, no backscatter)
• Value of Interest (VOI) calculated
from central 10% of image area for
flat field images
Clinical Experience….
• 80 CR readers (Agfa)
• 38 units required PMT replacement
(~50%)
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
0.1
0.25 0.
40.
55 0.7
0.85 1
1.15 1.
31.
45 1.6
1.75 1.
92.
05
Sensitivity
Fre
qu
en
cy
PRIOR TO
TESTING:
Mean = 0.853
SD = 0.233
53%
Compliant
Prior to testing:
Post QC and Repair:
0
0.05
0.1
0.15
0.2
0.25
0.3
0.1
0.25 0.
40.
55 0.7
0.85 1
1.15 1.
31.
45 1.6
1.75 1.
92.
05
Sensitivity
Fre
qu
en
cy
POST QC AND
REPAIR:
Mean = 0.971
SD = 0.099
100%
Compliant
Variation in Sensitivity
Exposure Indicator Accuracy
(computed radiography)
• How well matched should my readers
be?
- ±25% should be achievable
- TG-10 recommends readers be matched
within ±10%
- Can adjust the high-voltage settings on
some units
- In other cases have to replace the PMT
Indicator Accuracy
• EI
- ± 20% - IEC 62494-1
• PKA
- ± 35% - IEC 60601-2-43
- For PKA > 2.5 Gy-cm2
• Ka,i
- Vendor-defined
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
• DI is only useful if you have selected a
reasonable TEI
• Some vendors will provide recommended
TEI values
Establishing TEI Values
DR MANUFACTURERS
AEC Sensitivity Calibration
kVp Grid? Phantom Target Ka
(µGy)
GE Flashpad (CsI) 80 No 20 mm Al 2.5
Siemens (CsI) 70 No 0.6 mm Cu 2.5
Agfa DX-D (CsI) 70 No 25 mm Al 2.5
Philips 70 No 25 mm Al 2.5
Carestream DRX1-C 80 -- 0.5 mm Cu + 1.0 mm Al 2.5
Canon CXDI-70C 80 Yes 20 cm PMMA 2.5
• Can calculate expected EI or PV for target Ka under
AEC calibration conditions
AEC Calibration and EI
• VOI can matter
- Make sure to use the appropriate exam
tag
- Know the VOI used for EI calculation
• If using a target EI:
- Must verify accuracy of exposure
indicator and account for it
- For CR
• Time between image and readout must be
kept consistent
• Use QC plate or plate of median sensitivity
• The fewer sub-groups you have, the easier
your TEI values are to implement…
• Our Agfa CR systems currently set up with
three TEI sub-groups
• But are these right?
• Chest (TEI – 350)
• Non-Extremity (TEI – 400)
• Extremity (TEI – 1000)
Establishing TEI Values
Entrance Air Kerma
• Still requires establishing a target value for it
to be useful for ongoing QC
- Individual values extremely dependent on patient
size
- No standardized method for normalization
- Sample mean/ median < a DRL
• DRL specific to Exam
• DRL should be adjusted to account for patient
distribution OR
• DRL evaluation should be limited to specific
weight category (difficult to automate this!)
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
Setting Action Criteria
• Shape of distribution
• Expected variation
EI - Patterns
• Typically, 95% within +/- 2 DI
• SD in EI increases when manual techniques
are used
• Log-normal distribution of EI
• Normal distribution of DI
- SD in DI is independent of TEI
• Guidelines yet to be published
• Questions still to be answered:
- What is a typical (acceptable) level of variation in
the EI and DI
- Are recommended TEI values optimized?
Hulme et al, A Method for Deriving Exam-Specific Target Exposure Indices
(TEI) in Computed Radiography as a Function of a Reference TEI, TU-A-116-4
Color Coded Exposure Bar Ranges
- Green (Go)
• DI between -3 to +3 deviation units (aim 0)
• Represents less than a 2x change (±) in exposure index from target
• Images should be acceptable for exposure (no additional review required)
- Yellow (Caution)
• DI between -6 and -3 or +3 and +6 Deviation Units
• Represents a 2x to 4x change (±) in exposure index from target
• Images may be under or overexposed, but could still be acceptable for use
• Further review with supervision may be required to determine if repeat is
needed
- Red (Alert)
• DI < -6 or > + 6 deviation units
• Represents a greater than 4x change (±) in exposure index from target
• Images are probably significantly under or overexposed and are not acceptable
• Technique settings and targets should be checked
• Images should be reviewed with supervision and repeated (as needed)
Color Coded Exposure Bar Ranges
Table provided courtesy of Agfa HealthCare.
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
• EI = Exposure Index
• Approximate exposure to the plate
• LINEAR with exposure
• Double the mAs, EI doubles
• TEI = Target Exposure Index
• ‘Ideal’ exposure to the plate
• DI = Deviation Index
• How far above/below the TEI you are
IEC Exposure Index
Deviation Index (IEC 62494-1 )
• A DI of 0 indicates the exposure was at the
target value
• ±1 DI = ~ ±25% difference in exposure, or
+1/-1 density on a phototimer
• +3 DI = 2x the target exposure
• -3 DI = ½ the target exposure
TE I
E ID I lo g10
TG-116 Recommendations
Deviation Index
Exposure Deviation Index - DI Correction Needed
Over Exposed 6 Repeat if Image Saturated
Reduce mAs 0.25x*
>3 Caution
Decrease mAs 0.5x*
2 None
1 None
Aim 0 None
-1 None
-2 None
<-3 Possible Repeat
Increase mAs 2x*
Under Exposed -6 Repeat
Increase mAs 4x*
*If needed based on image quality or dose
Table provided courtesy of Agfa HealthCare.
General Radiography IV March 2011 47
Exposure Index
Deviation Index
75 kVp, 6.3 mAs
@Target Exposure:
EI = 389 (~ 400)
DI = -0.1 (~ 0)
Screen shot courtesy of
Agfa HealthCare
General Radiography IV March 2011 48
Exposure Index
Deviation Index
75 kVp, 3.2 mAs
½ mAs:
EI = 204 (~ 200)
DI = -2.9 (~ -3)
DI > -3 = green
Screen shot courtesy of
Agfa HealthCare
Exposure Indices
• Remember, clinical exposure indices will
vary with
- Manufacturer (different VOIs)
- Anatomical view
- Collimation
- Exposure indicator accuracy
• Manual techniques will have larger variation
than photo-timed exams
• Errors in detecting collimation borders can
result in inaccurate calculation of EI
- i.e. Merchant view for knees
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
Data Collection
• Paper (single site)
• Modality Performed Procedure Step (MPPS
report)
• RIS – extract and archive data (DICOM RDSR
or MPPS)
• Send images to a separate server and strip
data
Multiple Options…… (TG-151)
Data Collection
• Export data from workstation
- Easiest option but not always packaged in a
manner useful to the technologist
- Need the option to export data in both formats
• xml or csv
• SIMPLE report for routine QC
- Accidental or intentional deletion of data can
occur (i.e. during software upgrade by service
engineer)
Multiple Options…… (TG-151)
Defining a ‘Test’ Exam
Export Dose
Monitoring
Statistics
Screen shot courtesy of
Agfa HealthCare
Dose Tracking – Ongoing
Choose a Metric
Verify Indicator Accuracy
Establish Target Values
Education Education Education
Develop Action Criteria
Reporting Mechanism
RE-EVALUATE
Hulme et al, A Method for Deriving Exam-Specific Target Exposure Indices
(TEI) in Computed Radiography as a Function of a Reference TEI, TU-A-116-4
TEI vs. Exam Group
References: Exposure Indices
• Exposure Indicator for Digital Radiography, AAPM Report No. 116, 2009.
• IEC 6294-1, Medical electrical equipment – Exposure index of digital X-ray
imaging systems – Part 1: Definitions and requirements for general radiography,
2008
• Jones et al. ‘One Year’s Results from a Server-Based System for Performing
Reject Analysis and Exposure Analysis in Computed Radiography’, J Digital
Imaging, Vol 24. No 2 (April), 2011: pp 243-255
• Cohen et al. ‘Quality assurance: using the exposure index and the deviation
index to monitor radiation exposure for portable chest radiographs in neonates’,
Pediatr Radiol (2011) 41:592-601
References: Entrance Dose
• Akinlade et al. Survey of dose area product received by patients undergoing
common radiological examination in four centers in Nigeria, J. of Applied Med
Phys Vol. 13, No. 4, 2012: 188-196
• Hart et al., The UK National Patient Dose Database: now and in the future, Br. J.
of Radiol. 76 (2003), 361-65
• Hart et al., UK population dose from medical X-ray examinations, Eur. J. of
Radiol 50 (2004) 285-91
• Meghzifene et al. Dosimetry in diagnostic radiology, Eur. J. of Radiol 76 (2010)
11-14
References: PKA
• IEC 60601-2-43, Medical electrical equipment – Part 2-43: Particular
requirements for the safety of x-ray equipment for interventional procedures.
Geneva: International Electrotechnical Commission ed. 2.0, 2010
• Akinlade et al. Survey of dose area product received by patients undergoing
common radiological examination in four centers in Nigeria, J. of Applied Med
Phys Vol. 13, No. 4, 2012: 188-96
• Hart et al., The UK National Patient Dose Database: now and in the future, Br. J.
of Radiol. 76 (2003), 361-65
• Hart et al., UK population dose from medical X-ray examinations, Eur. J. of
Radiol 50 (2004) 285-91
• McParland et al. A study of patient radiation doses in interventional radiological
procedures, Br J Radiol. 1998; 71(842):175-85
• Nickoloff et al., Radiation Dose Descriptors: BERT, COD, DAP, and Other
Strange Creatures, Radiographics, Vol. 28. No. 5, 2008